Background of Original ACE Study● Department of Preventive Medicine, Kaiser Permanente in San Diego● Help understand how ACEs might affect health later in life● Track medical charts prospectively to analyze clinical courses forward intime● 2 groups of 13,000- 70% agreed to participate○ 26 to 90s (average 57y/o)○ 50% men and 50% women○ 80% white (including Hispanic), 10% Asian, 10% Black○ Mostly middle classOutcomes of the Original ACE Study● No phone calls from patients for the doctors doing the original ACE studyat Kaiser in 3 years● A number of patient compliments were received by the researchers● A small collection of thank you letters were sent to the researchers○ “Thank you for asking. I feared I would die and no one would ever know what hadhappened.”Why are ACE Scores Important to Patient Health?● High ACE scores associated with:○ distinct increase in likelihood of CAD in adult life, even in the absence of Framingham riskfactors○ likelihood of long term smoking● Interviews with obese and sexually abused patients led todiscovering long-term medical effects of seriously troubledchildhoods that were never documented.

“50% of practicing physicians and 30% of resident physicians reportedconfidence to screen, yet screening is much lower for practicingphysicians and almost non existent for resident physicians.” AdverseChildhood Experiences: Survey of Resident Practice, Knowledge, andAttitudeJanuary 2017

Implementing ACE at La Grange Memorial Hospital● July 2017: presentation given to residents and faculty about original ACEstudy● Every new patient and well visit over 17 would be given the ACEquestionnaire beginning in July

Initial ACE Implementation Protocol● Role play with program director as the patient● Patients with positive questionnaires would be asked “How are thoseevents still affecting you today?”● Patient would be listened to, made to feel accepted, and given feedbackthat noted their courage and allowed for a better understanding of theirproblems.

Initial Reluctances● “There is not enough time to ask about history of childhood physical orsexual abuse. Even a 5 minute intervention takes 30% of my time.”● “I feel uncomfortable inquiring about psychosocial issues; I’m afraid I maysay the wrong thing.”● I’m concerned that taking a history of childhood physical or sexual abusemay re-traumatize my patient. I fear I may harm the patient and upsetthem.”● “There is little I can do to help those patients who have revealed a historyof childhood physical or sexual abuse.”

March 2018 Resident Feedback“The ACE questionnaire helps to educate patients, and helps to identify whether it stemsfrom original traumatic experience or whether it is a slow and gradual process”“It opens doors for the patients.”“I use the questionnaire to help explain how these mentally stressful events causephysical issues when I perform OMT.”“I have found that continuing to give the writing assignment offers more structure and goalorientation for my patient”“I believe the questionnaire helps patients understand their present problems”“I now know what to expect with certain patients with their visits moving forward andbetter understand what they feel physically and emotionally.”“The patient stated they have now a more positive viewpoint ofthemselves.”“I’ve had multiple times patients cry on me, yet admit they feel better after the interventionand thank me for asking.”Not one resident reported a negative experience or any patient decompensating due to the ACEintervention.

Initial Faculty Focus Group April 2018Identified main barriers to screening:● Not enough time to ask about history of childhood physical or sexual abuse● Competing multiple primary care recommendations● Uncomfortable inquiring about psychosocial issue-“By screening with the ACE questionnaire, several of the other problems would also be addressed.”-Faculty advised NOT to reflexively refer to counseling with psychologist upon upon review of + ACEquestionnaire; instead, faculty requested the residents have scripts with different brief interventionsto give to a patient with + ACE score.

Revision to ACE Implementation Protocol● Residents educated on how to respond to positive ACE score with a brieffeedback:○ “I respect the courage it took to answer “yes” How does that adverse event affect youtoday? We are all taught to love people and use things. It was totally wrong to treat you asa thing. There is only one piece of good news regarding childhood adversity and that isyou can fully recover. I want you to complete the writing assignment before yourfollow-up appointment”● Residents educated on how to provide final feedback:○ “Remember, you never have to talk about what happened in the past with anyone. Weknow there is a direct relationship between these experiences and a person’s physicalhealth; we’ll explore these next time”

Real Patient Case: Anorexia Main past problems:● 20yo female with amenorrhea, low Vitamin D and low BMI● Touched by her uncle, followed up with counseling, reports parents knew thishappened● Lost virginity at 12. Boy was same age; she feels that was another traumaticexperienceCurrent problem:● Not over her past problems of abuse as it seems to have manifested into her nottaking care of her own body● She was used twice in her life, once when she was touched by her uncle andsecondly when she lost her virginity.● Feels she can’t grow up; feels stuck at age 20 mainly due to not having her periodReal Patient Case: AnorexiaPlan:● Patient feels she never gave anorexia program at Alexian Brothers a chance andwould like to see it through.● Discussed having a peer group is essential for disordered eating behaviorsResult:● Added youth screening for adolescents under 18 with CYW ACE-Q Child

Real Patient Case: T2DMMain past problems:● 53 yo female with uncontrolled T2DM● Molested by family member when she was younger and never mentioned it toanyone in her life prior to office visit for 3 month diabetes follow upCurrent problem:● She has treated her disease of diabetes like she has treated her experience ofsexual abuse: by suppressing it and ignoring the problems.● Result of uncontrolled diabetes and unresolved trauma from prior sexual abuseReal Patient Case: T2DMPlan:● Better compliance with diabetic medications and diet regimen coupled with writingassignment and counselingResult:● Decrease in HBa1c in part due to use of ACE● When she was asked if she were to live her life over again what change would shemake, “she said she would keep no secrets.”

Evolution of Data Collection- July 2018● All experiences with the ACE intervention were positive● Recognized that it is vital for the mental and physical health of the patientthat doctors are trained and feel confident in screening and intervening● 2021 intern class gave a baseline assessment of how confident they feelin screening and intervening before any training on a scale of 1 to 10● Baseline class average was 7.8 out of 10● Follow up assessment of confidence will be done in the future to assesstraining effectiveness

Class of 2021 FeedbackResident: “The patient seemed grateful and had a sigh of relief.”Patient: “Thank you for giving me these options to help treat me for my anxiety.”Patient: “I appreciate you focusing my history and not just the medical stuff. Thankyou for the writing assignment”“This is the first time I have been asked about this. This is really cool thatyou guys ask me about this. Thank you for asking.”No complaints or negative interactions reported

Faculty Assessment- September 2018“Senior residents are feeling more confident in screening. The biggest obstacle is time todiscuss history.”“I feel we are getting better with assisting residents and feel more comfortable inquiringabout psychosocial issues as well”“Residents seem more aware of ACE issues, they now have a template for a structuredresponse to + ACE and seem to be using it.”“Residents seem more confident in finding time to respond to + ACE screenings andcreating a follow up plan. They don't seem as overwhelmed by time required to screenand respond, and they are comfortable asking patient to follow up.”

What is next?● Continue training residents to become confident in screening andintervening● Continue to educate the residents about the importance of the ACEintervention to improve screening rates● Encourage other residency programs to screen and intervene in their ownpatients with + ACE scores on the initial visit so other medical problemscan be addressed